sf78_-_Certificate_of_Medical_Exam.pdf

TO BE GIVEN TO PERSON

EXAMINED WITH A PRE-

ADDRESSED "CONFIDEN-

TIAL-MEDICAL" ENVELOPE.

UNITED STATES CIVIL SERVICE COMMISSION

CERTIFICATE OF MEDICAL EXAMINATION

Form Approved Budget Bureau No. 50-R0073

Part A. TO BE COMPLETED BY APPLICANT OR EMPLOYEE

1. NAME (last, first, middle) 2. SOCIAL SECURITY ACCOUNT NO. 3. SEX

MALE

FEMALE

4. DATE OF BIRTH

5. DO YOU HAVE ANY MEDICAL DISORDER OR PHYSICAL IMPAIRMENT

WHICH WOULD INTERFERE IN ANY WAY WITH THE FULL PERFORMANCE

OF THE DUTIES SHOWN BELOW?

YES NO

(If your answer is "YES" explain fully to the physician performing the examination)

6. I CERTIFY THAT ALL THE INFORMATION GIVEN BY ME IN CONNECTION WITH THIS EXAMINATION IS

CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

(signature of applicant)

Part B. TO BE COMPLETED BEFORE EXAMINATION BY APPOINTING OFFICER

1. PURPOSE OF EXAMINATION

PREAPPOINTMENT

OTHER (specify)

2. POSITION TITLE

3. BRIEF DESCRIPTION OF WHAT POSITION REQUIRES EMPLOYEE TO DO

4. Circle the number preceding each functional requirement and each environmental factor essential to the duties of this position. List any additional essential factors in the blank spaces. Also, if the position involves law enforcement, air traffic control, or fire fighting, attach the specific medical standards for the information of the examining physician.

A. FUNCTIONAL REQUIREMENTS

1. Heavy lifting, 45 pounds and over

2. Moderate lifting, 15-44 pounds

3. Light lifting, under 15 pounds

4. Heavy carrying, 45 pounds and over

5. Moderate carrying, 15-44 pounds

6. Light carrying, under 15 pounds

7. Straight pulling ( hours)

8. Pulling hand over hand ( hours)

9. Pushing ( hours)

10. Reaching above shoulder

11. Use of fingers

12. Both hands required

13. Walking ( hours)

14. Standing ( hours)

15. Crawling ( hours)

16. Kneeling ( hours)

17. Repeated bending ( hours)

18. Climbing, legs only ( hours)

19. Climbing, use of legs and arms

20. Both legs required

21. Operation of crane, truck, tractor, or motor vehicle

22. Ability for rapid mental and muscular coordination simultaneously

23. Ability to use and desirability of using firearms

24. Near vision correctable at 13" to 16" to

Jaeger 1 to 4

25. Far vision correctable in one eye to 20/20 and to 20/40 in the other

26. Far vision correctable in one eye to 20/50 and to 20/100 in the other

27. Specific visual requirement (specify)

28. Both eyes required

29. Depth perception

30. Ability to distinguish basic colors

31. Ability to distinguish shades of colors

32. Hearing (aid permitted)

33. Hearing without aid

34. Specific hearing requirements (specify)

35. Other (specify)

B. ENVIRONMENTAL FACTORS

1. Outside

2. Outside and inside

3. Excessive heat

4. Excessive cold

5. Excessive humidity

6. Excessive dampness or chilling

7. Dry atmospheric conditions

8. Excessive noise, intermittent

9. Constant noise

10. Dust

11. Silica, asbestos, etc.

12. Fumes, smoke, or gases

13. Solvents (degreasing agents)

14. Grease and oils

15. Radiant energy

16. Electrical energy

17. Slippery or uneven walking surfaces

18. Working around machinery with moving parts

19. Working around moving objects or vehicles

20. Working on ladders or scaffolding

21. Working below ground

22. Unusual fatigue factors (specify)

23. Working with hands in water

24. Explosives

25. Vibration

26. Working closely with others

27. Working alone

28. Protracted or irregular hours of work

29. Other (specify)

Part C. TO BE COMPLETED BY EXAMINING PHYSICIAN

1. EXAMINING PHYSICIAN'S NAME (type or print)

2. ADDRESS (including ZIP Code)

3. SIGNATURE OF EXAMINING PHYSICIAN

(signature) date)

IMPORTANT: After signing, return the entire form intact in the preaddressed "Confidential-Medical" envelope which the person you examined gave you.

STANDARD FORM NO. 78

OCTOBER 1969 (REVISION)

CIVIL SERVICE COMMISSION

FPM 339

STANDARD FORM 78 (Rev. 10-69) Page 2

NOTE TO EXAMINING PHYSICIAN: The person you are about to examine will have to cope with the functional requirements and environmental factors circled on page 1 of this form. Please take them, and the brief description of job duties above them, into consideration as you make your examination and report your findings and conclusions.

1. HEIGHT: FEET, INCHES. WEIGHT: POUNDS.

2. EYES

(A) Distant vision (Snellen): without glasses: right left

; with glasses, if worn: right left

(B) What is the longest and shortest distance at which the following specimen of Jaeger No. 2 type can be read by the applicant? Test each eye separately

Jaeger No. 2 Type employees in the Federal classified service as may be requested by the Civil Service Commission or its authorized representative. This order will supplement the Executive Orders of May 29 and June 18, 1923 (Executive

Order, September 4, 1924).

without glasses:

R. in. to in.

L. in. to in.

with glasses, if used:

R. in. to in.

L. in. to in.

(C). Color vision: Is color vision normal when Ishihara or other color plate test is used? YES NO

If not, can applicant pass Iantern, yarn, or other comparable test? YES NO

3. EARS: (Consider denominators indicated here as normal. Record as numerators the greatest distance heard.)

Audiometer (if given) :

RIGHT EAR

20 ft.

; LEFT EAR

20 ft.

250 500 1000 2000 3000 4000 5000 6000 7000 8000

4. OTHER FINDINGS: In items a through i briefly describe any abnormality (including diseases, scars, and disfigurations). Include brief history, if pertinent. If normal, so indicate.

a. Eyes, ears, nose, and throat (including tooth and oral hygiene)

b. Head and back (including face, hair, and scalp)

c. Speech (note any malfunction)

d. Skin and lymph nodes (including thyroid gland)

e. Abdomen

f. Peripheral blood vessels

g. Extremities

h. Urinalysis (if indicated) Sp. gr. Sugar Blood

Albumen Casts Pus

i. Respiratory tract (X-ray if indicated)

j. Heart (size, rate, rhythm, function) Blood Pressure

Pulse

EKG (if indicated)

k. Back (special consideration for positions involving heavy lifting and other strenuous duties)

l. Neurological and mental health

CONCLUSIONS: Summarize below any medical findings which, in your opinion, would limit this person's performance of the job duties and/or would make him a hazard to himself or others. If none, so indicate.

No limiting conditions for this job

Limiting conditions as follows:

STANDARD FORM 78 (Rev. 10-69) Page 3

FOR AGENCY USE ONLY

Part A. TO BE COMPLETED BY APPLICANT OR EMPLOYEE

1. NAME (last, first, middle) 2. SOCIAL SECURITY ACCOUNT NO. 3. SEX

MALE

FEMALE

4. DATE OF BIRTH

5. DO YOU HAVE ANY MEDICAL DISORDER OR PHYSICAL IMPAIRMENT WHICH

WOULD INTERFERE IN ANY WAY WITH THE FULL PERFORMANCE OF THE

DUTIES PREVIOUSLY NOTED?

YES NO

(If your answer is "YES' explain fully to the physician performing the examination)

6. I CERTIFY THAT ALL THE INFORMATION GIVEN BY ME IN CONNECTION WITH THIS

EXAMINATION IS CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.

(signature of applicant)

1. EXAMINING PHYSICIAN'S NAME (type or print)

2. ADDRESS (including ZIP Code)

3. SIGNATURE OF EXAMINING PHYSICIAN

(signature) (date)

IMPORTANT: After signing, return the entire form intact in the pre-addressed "Confidential-Medical" envelope which the person you examined gave you.